In today’s post I risk upsetting The Veteran even more, by featuring a new comment from Joe Crea, a doc who’s run off to academia and so doesn’t need to care what anyone thinks of him! Joe is peeved at my comment in Friday’s post that:

Hence I’m told again and again that government healthcare would be inefficient (as I heard from a Democrat I met tonight), despite the fact that Medicare’s admin costs are 3% while private insurance’s costs are 8-15%. You’d think that the onus would be on the defenders of the staus quo to show why a change would be worse.

I later went on to say:

But it is a long way from being a government dictated-system like that of Canada or the UK. Given the record of American private health care, that may be a bad thing…

Joe thinks that there is a flaw in my logic:

One of my pet peeves is the presenting of “the fact that Medicare’s admin costs are 3%” without appropriate qualification or explanation. I have attached such a succinct qualification here, courtesy of Healthleaders.

“Medicare overhead has the appearance of a gold standard: 2.1 percent overhead compared to a commercial average of 13 percent and a “best practices” company commercial average in the range of 5-8 percent. Medicare clearly has economies of scale, but its overhead figure is a bit misleading. The average per-member-per-month premium for commercial HMOs in now in the $200-$250 range, while the typical PMPM for Medicare is in the $600 range. If the Medicare PMPM were $200 rather than $600, then it would have an administrative overhead of 6.3 percent rather than 2.1 percent-still very good, but not out of the range of the very lowest-cost private insurers.

“For that relatively low overhead, Medicare offers only a single product (little choice except in urban areas where Medicare+Choice is available), provides limited medical management (and that seemingly by lawsuit), conducts provider contracting by fiat (negotiations take place in Congress), and has almost no marketing costs (no competitors).”

The other two things that are not mentioned are the hiding of the debt service to other areas of the government, and the shifting of administrative costs to providers by way of mandates and voluminous paperwork.

Now the article Joe references does take a look at the “best practice” plans with the lowest medical loss ratios. They tend to be big monopoly Blues in rural states, or staff/group model HMOs which practice shoulder to shoulder restraint (or push medical management doen to the physician level). But with the exception of Kaiser they are not the core private health insurers that dominate the national market. Those guys not only have very high admin costs (or in the jargon “low medical loss ratios”) but are making them higher. Following United Health Group raising its profit forecasts CBS Marketwatch reports that Health insurers (are) getting bigger cut of medical dollars:

From 2000 to 2003, medical loss ratios for the 17 companies dropped from an average of 84.8 percent four years ago to 81.5 percent last year. So while medical expenses have increased, the proportion of dollars devoted to them has dropped.

So for the bigger players getting bigger, more money is sticking with them, so adminstrative costs are going up not down. And, duh, that’s the way the system is designed. Everyone at Anthem, Pacificare, Wellpoint, Aetna, etc, etc is incented to try to reduce their medical loss ratio.

Now that might not be such a bad thing if they were truly managing care, auditing for quality, and increasing the amount they’re spending on administrative functions in order to reduce the amount being spent on medical care. But if you think that’s what they’ve been doing for the last 5 years, you really haven’t been paying attention. I talked to a VP of HR at a very, very big telecoms company last week, and she disputed my notion that the health plan’s clients (like her) haven’t been holding their feet to the fire. She claimed that they’d done huge amounts to try reduce their costs. I said, “Tell me another industry that supplies you from which you’ve accepted 15% annual increases in costs for no perceived additional benefits for the last 5 years in a row?” The HR VP went very quiet.

Now maybe Joe is right and we should be calculating Medicare’s admin charge on its higher cost per case. But even at 6% it looks pretty good compared to all but monopoly Blues plans. In other words Medicare and those plans all share a bunch of characteristics leading to their low overhead (from the same Healthleaders article):

• Economies of scale in a single state (Blue Cross Blue Shield of Alabama and Blue Cross Blue Shield of Tennessee)
• A narrow geographic focus (Capital Group, Fallon, Kaiser)
• Off-loading medical management expenses to capitated medical groups or IPAs (Kaiser, Fallon, Capital Group)
• Market leader position (Fallon, Capital Group, Blues of Alabama and Blues of Tennessee), lowering marketing costs
• Comparatively narrow product offering (Fallon, Capital Group, Kaiser, BCBS of Alabama)

I’d actually dispute Joe’s point about Medicare off-loading admin work to providers. Given the lack of UR in the Medicare system I think it off-loads less admin onto providers than private insurers–certainly it doesn’t create more. And because it’s so big and only needs things done one way, it’s a lot less work for providers than dealing with 5-10 plans of the same cumulative size who all want things done just their way (the thing that HIPAA simplification was supposed to do). But even if he’s right, Medicare’s adminstrative cost is as low as it is because of all the things he finds so terrible such as being able to set its own provider rates, only offering a limited “product” line up, limited medical management, etc. The problem is that private health plans are “charging” through the nose to deliver all those things and yet it just costs more and more with no apparent gains. And those “charges” are increasing (or the MLRs are going down).

So let me ask one more time. Why is the onus on the government program to prove that it is more administratively efficient than private plans when it already is, and they are getting less efficient?

Coda: I don’t want you to think that I’m a huge fan of the way Medicare works. I think it needs drastic changes, including upping its oversight of the system and changing the way it pays providers to a performance-based reimbursement system. And I said as much in the very first post of THCB. But given its huge clout and the government’s ability to change the law, I think a reformed Medicare could do that in a way that will improve the care delivered at a lower cost, bloody battle though that’ll be. The private plans’ record of the the last 5 years shows no sign that they could.

Bush has certainly been attacking Kerry on his health care program. Jonathan Cohn is an editor at the New Republic who specializes in health care and is currently a Kaiser Family Foundation media fellow. For those of you who don’t track the political leanings of the weeklies, the New Republic is the Clintonian Democratic magazine, way to the right of the leftish The Nation, while far to the left of the conservative National Review. Cohn’s latest piece has been reproduced on CBS web-site which may (or more likely may not) hint at whom CBS’ parent Viacom wants to win the election.

In any event he does a much better job than Kerry has done himself on crying bullshit at Bush’s attempt to call the Kerry plan a government takeover of health care. In the article called A Guide To Bushspeak On Healthcare Cohn says:

The Clinton health care plan really was a government-run health plan (albeit one that was hardly the menace its critics warned it would be). That’s simply not the case with Kerry’s health plan, for reasons that I (among many others) have already written about. Today, in fact, a group of 68 health care policy experts led by Mark Peterson at the University of California at Los Angeles, released a petition calling upon the Bush campaign to end its gross distortions of Kerry’s plan. “Although Senator Kerry’s proposals should be subject to a full analysis of their cost and impact, any claim that they amount to ‘government-run health care’ or a ‘government takeover’ of the health care system or of health care decision-making is simply inconsistent with the facts. We are not aware of any expert in health care or health care finance, whatever his or her political orientation, who believes otherwise.”So why would Bush produce an ad like this – and continue to raise the specter of “government-run health care” – even though the charges are now widely known to be false? Because he keeps getting away with this dishonesty.

Meanwhile the 68 academics that Cohn quotes as opposing the Bush rhetoric represent a middle of the road group of health care economists. The only notable exceptions are Alain Enthoven of Stanford (although his one time colleague Richard Kronick is in the group) and Mark Pauly of Univ. Pennsylvania, the foremost defender of the status quo of the healthcare market. It’s also missing a certain (ex) Stanford Business School professor called Mark McClellan, who’s written extensively about health care and seems to know a thing or two about it. He might want to want to sign this too, but I think his boss might be a little unhappy with him!

Part of the problem is that both sides get their say on the talk shows, with no one (aside from the Columbia Journalism Review or John Stewart) being able to say “this is true — that isn’t”. On a personal note I tend to be able to demolish many arguments I meet with from people complaining about, say, Canadian health care or how inefficient the government program would be, by quoting referred studies that tell the truth. (It’s good to be a researcher wonk when these arguments come up). But there are two problems. One is that a well-financed opposition can cite its own fake studies, and two, no one gives a dam about studies when they have their own fears and anecdotes to back them up.

Hence I’m told again and again that government healthcare would be inefficient (as I heard from a Democrat I met tonight), despite the fact that Medicare’s admin costs are 3% while private insurance’s costs are 8-15%. You’d think that the onus would be on the defenders of the staus quo to show why a change would be worse. But instead–and I realize why–Kerry is running away from any program that could be described as a “government takeover”, even though a rational candidate should be able to defend it. And if I hear Bush say one more time that we have the best healthcare system in the world…..well to say the least he needs to be told by someone that there is a difference between having the most technologically advanced medical spottily applied, and having the best health care insurance and delivery system. There’s a reason we’re ranked number 37 by the WHO, and it’s not just that they’re a bunch of cheese-eating surrender monkeys.

Believe it or not, there’s a very detailed and fair explanation of the Kerry plan by the Heritage Foundation (they of the vast right-wing conspiracy) which goes through it line by line. Heritage of course prefers a consumer-based HSA-type system and (as debated ad nauseam on THCB) as that’s not part of the Kerry agenda they don’t approve. But despite their many criticisms of the Kerry plan, they represent it mostly fairly, unlike their friends on the Republican national committee and at the AEI. They say:

Based on independent estimates, it appears that the Senator’s proposals would significantly increase federal health care spending while sub­stantially reducing the number of Americans who are without insurance coverage. At the same time, he would refrain from undertaking any substantial reform of either private health insurance markets or government health care programs, including Medicaid.

Another detailed commentary on the plan comes from Jeff Lemieux at Centrists.org. Lemiuex’s extremely long examination of the plan suggests that it could be basis for bi-partisan reform to the system, as it relies on a mix of government and private action (or liberal and conservative ideas).

While I’m increasingly convinced that Kerry will win a very close election, I’m inclined to doubt that he’ll get anything like his plan past a Republican house and a very evenly divided Senate. So his plan is a starting point which may–if anything passes and that’s a longshot–work to get more people at the bottom into public programs, allow those in the middle to buy into the FEHBP, and slowly implement DSM programs and other cost saving methods into a more regulated private sector (and hopefully into Medicare too). But it is a long way from being a government dictated-system like that of Canada or the UK. Given the record of American private health care, that may be a bad thing. But the point is government-run health care can’t survive the political rhetoric here. It would be nice if just occasionally Bush would talk something akin to the truth about this issue, but then again why break a 4 year habit?

Ross at the The Public Health Press has a just excellent summation of the flu vaccine issue, in the context of the two rather odd replies from Bush and Kerry to that question in last night’s debate.

Harvard economist Anna Sinaiko has an article in Health Affiars suggesting that the SB 2 (or Prop 72) “pay or play” law will cause unemployment and reduced wages for those Californians it covers should it pass. Her analysis is manna from heaven to those opposing the bill. Here’s the key conclusion.

Implementing SB 2 will change the behavior of employers affected by the legislation, with consequences for California’s labor market and uninsured citizens…A more likely scenario is that some of the cost of health insurance will be passed to consumers, some felt by workers as unwelcome wage reductions, and some avoided by firms as they restructure their workforces. In California, workers at firms not offering benefits are more likely to be young males earning less than workers at firms that offer insurance; SB 2 will affect this group most adversely.

As a forecaster I was trained to that there’s a big difference between being broadly accurate and precisely wrong. Sinaiko’s detailed analysis of Prop 72’s likely impact falls into the latter category. Increasing labor costs (which is what SB2 will mean) may result in overall lower wages, but increased labor costs are more likely to result in lower profits. Sinaiko never mentions profits as a share of corporate revenues. A senior VP from Fidelity said, in a talk I heard on Monday, that corporate profits as a share of revenues are currently at an all time high, while wages are at their lowest in real terms for 30 years. Why should the costs of SB2 come out of wages rather than profits, given that one of them has been going up and the other down?

Sinaiko correctly points out that the vast majority of jobs affected by SB2 cannot be moved out of California, unless San Franciscans want to drive to Reno to get a cheeseburger. So the total amount of money going into these businesses is likely to stay roughly the same. She almost neglects to mention that the wages of many of those covered by SB2 are at minimum wage or the equivalent (and legally enforced) “living” wage in some cities, so their wages can’t be reduced, and the cost of hiring and managing more part-time employees may exceed the increase in labor costs from SB2.

The broad analysis tells us that, whatever the libertarians say, laws demanding an increase in the lowest levels of compensation (which is in effect what SB 2 is) have almost no impact on unemployment rates, which are driven by the overall economy I lived in the San Francisco Bay Area in 1999 when no amount of money could hire people. I was here in 2002 when you couldn’t get a job no matter how little money you’d work for. (And according to another talk from a different Fidelity executive, all the jobs that could be, had already been moved to India). At both times the minimum wages was the same. In the UK the Labour government brought in a minimum wage in 1999. Today the unemployment rate in the UK is the lowest it’s been since 1972, and studies show no negative impact on employment among low wage workers.

Common sense also suggests that the people who oppose Prop 72 think they have something to lose. Who are those people? They are the big fast food chains and the non-unionized discount stores, who have spent over $8m against it. If they believe that they’ll be able to push all the costs of Prop 72 into their “labor” segment and have none of it come out of their “profit” segment, why would they bother opposing it?

UPDATE: Health Affairs has published a rather more academic version of this letter in its online section.

Ken Thorpe writes in the NEJM on the uninsured. He’s been in the Clinton Administration, and he’s the author of the study that says the Kerry plan’s cost will be in the $650 billion range rather than the AEI’s $1.5 trillion estimate. So you can take his view the way you want to. But what he basically says is that both Bush and Kerry’s plans are incremental and neither of them will cure the problem of the uninsured. Then again I just had dinner with an (only) Fox-News watching, Bush supporter from Texas who told me –in all seriousness–that not only was my analysis of the health care system biased because the richest people in the world come here for their medical care (the Sultan of Brunei?) and so we have the best system in the world–whatever the Economist (which prefers the Swiss system) and WHO say (they rank the French first). He also told me that Iraq is in good shape, the Abu Grahib scandal wasn’t a big deal, all the networks are biased in Kerry’s favor and that uninsurance for 45 million wasn’t a problem. So given that’s the attitude of many on the Republican side (and I’m sure it is), it’s unlikely that this post is going to change many minds. However, Thorpe correctly says that:

Adults and children without insurance are given diagnoses at later stages of illness, receive fewer preventive and curative medical services, and have worse health care outcomes than those with insurance…..First, Kerry would extend coverage by Medicaid and the State Children’s Health Insurance Program (SCHIP) to people who are currently ineligible for such coverage — single adults and childless couples living below the poverty line and parents with incomes of less than 200 percent of the poverty line. He has also proposed extending the same coverage to more children by raising the cutoff level to 300 percent of the poverty line. Instead of continuing today’s federal–state matching arrangements in these programs, Kerry would have the federal government finance 100 percent of the costs of the expansion. Full federal funding is likely to result in higher rates of program enrollment.

This past week a progressive pressure group, Vote Kids, introduced several leading pediatricians in a Washington DC press conference to make a joint statement about children’s health care in America. The pediatricians included six past presidents of the American Academy of Pediatrics all supporting Kerry’s effort to extend coverage to all children. HHS Secretary Thompson responded to this week’s activity by calling the pediatricians “demagogues“ and said: “It is absurd and despicable that doctors are playing politics with children’s lives“. That sounds a little over the top to me, even though Sydney at Medpundit points out that some doctors (including her) don’t agree with the AAP on this. (Syd also has this great post on the relative risk of Vioxx, which I agree with BTW, showing my libertarian side…). Mitch Arnowitz from Vote Kids wrote to me saying:

8 million children and youth don’t have health insurance. We think that the present administration does not have a plan to provide health coverage to America’s children, and that their current tax and budget priorities are eroding hard won health care gains for children.

That statement is undeniably true so I’m going to respond to my Texan friend’s charge of bias by being biased in favor of the truth. I try not to use this blog as a soapbox, but try reading this story about a young woman born with a “pre-existing condition” who is disabled and has a terrible story, and you’ll understand why emotionally I feel that we need a single universal insurance pool for the most vulnerable. Kids are the cheapest and easiest to cover, and there is no way that even the crustiest Texan Republican can explain to me that its their fault if they are uninsured. So morally I think we should get them coverage.

You can give to Vote Kids, here. And in equal fairness you can give to Bush here. How unbiased is that?!!

UPDATE: Linkmeister Steve accuses me of going into “he said, she said” here without actually calling Thompson or Vote Kids on the truth. He cites a neat article from the Columbia Journalism Review, which tries to tell the truth on the candidate’s health care plan objectively rather than just allow each side’s spin to come out unhindered. The way it should be done is “he said, she said, we say”.

I honestly think I do the “we say” bit but let me reiterate. Vote Kids is right, in that there are more than 8 million uninsured kids and that uninsured kids (and adults) tend to be poorer and get fewer health services than insured ones. The KFF factsheet shows that. Tommy Thompson claims that Bush has done great stuff for kids–and to be fair the number of uninsured kids has gone down, due to SCHIP and Medicaid. But that’s not good enough, and the Bush “program” has no plans to further reduce that number. The Kerry plan, not that it’ll pass as is, does. And furthermore, insuring kids is relatively cheap and very good value in terms of future benefit to society–second only to getting them an education. We wouldn’t (I hope) as a society accept non-universal education for kids. At least Kerry wants to get us there for healthcare.

Proposition 72 is a referendum on the California pay or play bill that passed in the waning days of Gray Davis ill fate-second term before the Governator swept all before him a year ago. The Yes on 72 bill has been out with some TV commercials–most of their money comes from Unions while the players like Wellpoint are neutral. The opponents are the large fast food chains who would be forced to provide health care coverage to their workers. I listed out who was pro- and con a while back, with the those opposing having raised much more money, of course.

The bill won’t do too much about California’s uninsurance crisis–maybe putting 1.4 million out of 6 million uninsured into coverage. The problem is concentrated in smaller firms, who politically can’t be forced in providing coverage. But a band-aid on a wound is better than nothing for supporters of universal insurance. My feeling is that big businesses that do not offer benefits (e.g. the Walmarts of the world)are competing unfairly with those who do–while the taxpayer picks up the tab. A RAND study shows that 95% of businesses with more than 50 workers already offer insurance to their employees. (I mean offer insurance that is taken up, as offering insurance that the worker can’t afford is a cop out). But 15% of all workers in that size of firm do not get coverage, mostly because they can’t afford (see chart 9). The bill maxes out the workers premium share at 20%.

So it’s the big businesses paying low wages (i.e. fast food) that are being targeted here. And most of them can’t easily move, unless Los Angelinos are prepared to drive to Phoenix for their burgers. Of course the No on Prop 72 folks are keen to suggest that this bill will put mom & pop businesses under, but the bill doesn’t apply to businesses with fewer than 50 employees. So it’s a little amusing that the “No on 72” guys got caught faking their most seen ad. It was supposed to be a poor immigrant restaurant owner. But the restaurant in question wouldn’t be affected by the bill, and the “owner” was an actress. Oops.

For more on this and other California propositions see the California HealthCare Foundation site.

A couple of days back in a piece on HSAs I challenged someone, anyone to speak up for HSAs against this criticism from Don McCanne. While I’m not a straight single payer advocate like Don, we both believe in one risk pool/universal insurance. And HSAs destroy that concept. Here’s Don’s logic in full:

Imagine everyone having a health savings account (HSA) and a low cost, high deductible insurance plan. Now let’s fund our entire health care system, currently at $1.8 trillion, with the HSAs and high deductible plans. Keep in mind that 80% of health care costs are used by the 20% of individuals with serious acute and chronic disorders.

Current contributions for HSAs are capped at $2600 for individuals and $5150 for families. For illustrative purposes only, let’s assume that each individual has $2000 in an HSA. That means that the 294 million U.S. citizens would have $588 billion in HSAs. For the 20% with significant needs, their $117 billion would be rapidly depleted, having been spent of health care. The healthy 80% might use an average of $300 per person in incidental health care costs, depleting their accounts of $70 billion. The “beauty” of HSAs is that the $401 billion remaining in the HSAs of the 80% who are healthy will be converted into retirement pensions. That’s a great deal for the majority of individuals who remain healthy. But that removes about $400 billion from the $1.8 trillion that we are already spending.

HSAs will have funded $187 billion of the $1.8 trillion, leaving costs of $1.61 trillion for the catastrophic care of the 20% of individuals with greater needs. But after the HSA funds are removed from the equation, there is only $1.21 trillion left to pay for care that currently costs $1.61 trillion.

Where will the $400 billion shortfall come from? Not from most of those with greater needs since current health plans already fail to provide adequate financial security, and this would add an average additional burden of $6800 per person. The only practical solution would be to increase the premiums for the high deductible coverage to a level that would fund the full balance of the $1.8 trillion that we are spending.

There are two significant consequences of this. First, the low cost, high deductible plans would no longer be low cost. Second, there is a perversity of the fundamental principle of health insurance, in which funds of the healthy normally help to pay for care for the sick, in that, with HSAs, the funds of the sick help to pay for the retirement accounts of the healthy.

Landon Alger (the government employee you may recall from his contributions a few weeks back) took up the challenge, and just to really annoy The Industry Veteran, I’m printing it here. Interestingly enough there is a teensy bit of common ground between him and McCanne, the single payer advocate. I’m coming over all moderate and centrist. Perhaps I’d better go sit down. Here’s Langdon’s piece:

Single payer lunatic Don McCanne provides a simple example of what can happen when HSAs are applied on a macro-scale. The healthy 80% realize savings not just on health insurance premiums, but also on actual healthcare costs. They are definite winners (therefore implying a loser) that get a nifty new savings vehicle-a health pension. These individuals have no need for the single payer paradigm and would not benefit from such a system. For these 80%, the single payer system introduces inefficiencies and would add to our national healthcare expenditures.

The remaining 20% that need 80% of the healthcare dollars (these ratios are not set in stone and one of the goals of national healthcare policy should be to flatten the curve) are now definitely losing out at this point. They need the taxpayer subsidized single payer type system and aggressive, outcome-incentive based disease management programs on a national level. While it is surely difficult to implement a system where individuals must qualify into the “single payer system” (yes, I know, it’s really not pure single payer anymore), there is no definite exclusiveness of HSAs and single payer. McCanne isn’t wrong, just incomplete.

Additionally, current HSA law does have a few flawed provisions. The HSA should only be able to be used for healthcare costs, and not simply another IRA once a person gets to age 65. And at death any remaining HSA balance should be forfeited into the single payer system.